‘ We’ ve changed our emphasis from what’ s good for people to successful treatment exits,’ he said, and he had clear advice.‘ Get them on doses that work. Suboptimal doses make things worse.’
The optimal doses were usually between 60-120mg of methadone and 12-16mg of buprenorphine. However the average doses were 46.6mg of methadone, 10.6mg of buprenorphine and 9.3mg of buprenorphine / naloxone. So why was average dosing so low?
‘ There’ s fear of diversion,’ he said. But using buprenorphine as an example, 16mg was the best dose, as‘ at this dose it blocks. It lets them engage with getting better. Choose good clinical dosing and let people choose life.’
With representatives of some of the major treatment agencies in the room, the conference was an opportunity to debate sector-led solutions.
‘ This is not a happy conversation to be having – it touches people’ s lives every day,’ said Karen Tyrell, Addaction’ s executive director of external affairs. It also had a huge impact on frontline workers, and‘ every organisation should be doing more about that’. To reduce drug-related deaths we needed to improve penetration rates –‘ make sure our services are easy to get into,’ she said.
With this in mind, a panel session brought together directors from Addaction, CGL and Turning Point, together with Paul Hayes of Collective Voice, the body representing the sector’ s major treatment agencies.
‘ We want to develop a shared statement,’ said Hayes.‘ We’ re not just looking at overdoses, but excess deaths. This is a population with compromised hearts, lungs, mental health problems, who are in and out of prison and whom the rest of the population shuns.’
There were key areas to look at. These included helping service users to recognise who’ s most vulner- able; improving clinical interventions and NHS engage ment; and making pathways and appointments easier.
‘ These things are difficult to navigate – God help you if you’ re in your 40s and have had life experience that leaves you feeling compromised,’ said Hayes.‘ How do we make sure we have a system that has the
right balance between offering people recovery but not pushing them into it too early? How do we engage with people who are most at risk – people outwith the treatment system?’
‘ We want to be able to move people at risk up the system,’ said Dr Prun Bijral of CGL.‘ Our key workers are really pushed right now – we need to help them …. We need to have ambition. There’ s a lack of penetration – people are not seeing our services as attractive. We need to look at the evidence base and prioritise.’
Another challenge for providers, he said was‘ to factor in 30 per cent or 40 per cent for non attendance loss’.
Dr David Bremner of Turning Point agreed with the need to adapt to circumstances.‘ We have to look at what harm minisisation advice is, in the context of massively slashed budgets – people are sometimes late or angry and we have to take this into account.
Bremner wanted to see better liaison to get things done. Getting commissioners along to morbidity and mortality meetings had‘ borne phenomenal fruit’.
‘ We now have 100 per cent naloxone penetration,’ he said.‘ When there’ s resistance to this, you have to hit it with a sledgehammer.’
Furthermore, he wanted providers to think outside of the usual competitive mindset.‘ We need to, as a group, set industry standards, so no one is scripted without naloxone. We also need to break the“ dare to share” attitude,’ he said, rather than doubling up to all invest in new things from scratch.
Addaction’ s executive director of operations, Anna Whitton, also spoke of the need to look past the competitive element.‘ This is about putting differences to one side, this is about people dying,’ she said.‘ If we find the right partnerships we can make quick differences to what’ s happening.
‘ We need to listen to service users and facilitate access to appointments, particularly early in their treatment,’ she said.‘ How do we make the system more responsive to people? How can we work flexibly and smarter?’
In Bremner’ s view,‘ things we’ ve done very poorly’ included accepting payment by results.‘ There are people who are seen as“ not engaging”, but they are
‘ there’ s a key message for the workforce... Your fundamental job is to keep people alive. Be as aspirational as you want, but keep people alive.’
Karen tYrell
engaging, such as with the pharmacist. They’ re just not engaging with you. We need to be more clinically authoritative.’ Providers also needed to‘ push back against CQC’, he believed, adding‘ I haven’ t come across any inspection that’ s going to stop deaths’.
‘ I’ m a big fan of low threshold prescribing – but try and get that past CQC now,’ he said.‘ It got people on and into treatment. But I believe we’ re moving back to a more robust harm reduction model and low threshold prescribing is part of that.’
‘ There is a mood shift,’ agreed Hayes.‘ Harm reduction never went away but it became unfashion- able. As the drug-related deaths agenda comes to dominate, it will be easier to talk in those terms.’
‘ Some people just want a safe place to use,’ added Bijral.‘ We have to work with coroners and commissioners. We have to get people into treatment.’
‘ Part of shifting the balance sits within treatment services,’ said Harry Shapiro, director of DrugWise, from the audience.‘ Harm reduction has become quaint, or a political watchword for legalisation. But we need to bring harm reduction back into the heart of the mainstream.
‘ There’ s a key message for the workforce,’ concluded Karen Tyrell.‘ Your fundamental job is to keep people alive. Be as aspirational as you want, but keep people alive.’ DDN
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